Healthcare Provider Details

I. General information

NPI: 1154302081
Provider Name (Legal Business Name): MICHAEL JAMES POULOS OTR L CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 BROADWAY
BELLINGHAM WA
98225-3039
US

IV. Provider business mailing address

PO BOX 1557
BELLINGHAM WA
98227-1557
US

V. Phone/Fax

Practice location:
  • Phone: 360-676-4263
  • Fax: 360-671-3366
Mailing address:
  • Phone: 360-676-4263
  • Fax: 660-671-3366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: